Exploring sustainable care pathways - a scoping review

Background Patients with mental health problems experience numerous transitions into and out of hospital. Aim The review studies assessing clinical care pathways between psychiatric hospitalization and community health services. Methods We used publications between 2009–2020 to allow a broad scoping review of the published research. Sixteen review-articles were identified, 12 primary studies were chosen, both on care pathways in the transition between psychiatric hospital and community. Results Organizational issues: Systems and procedures to ensure clear responsibilities and transparency at each stage of the pathways of care. Resources: Information-technology in objectively improving patient outcome. Information/documentation: Providing patients with adequate structured information and documented plans at the appropriate time. Patient/families: Continuous collaborative decision-making. Clinical care and teamwork: Collaboration between mental health and other professionals to guarantee that planned activities meet patient need. Ethical issues: Respectful communication and patient-centred, non-humiliating care. Conclusions System and procedures ensure clear responsibilities and transparency. Information technology support decision-making and referral and objectively improve patient outcomes in care pathways. Collaboration between mental health and other professionals guarantee that planned activities meet patients’ needs along with regular meetings sharing key information. Around-the-clock ambulant-teams important to transition success. Informed-shared decision-making between parties, support patient participation and respectful communication. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08863-w.


Introduction
Care pathways are used increasingly worldwide to organize patient care. However, there are different views about their effectiveness, outcomes, and impacts [1,2]. There is a growing interest in extending care pathways in both primary and mental health care to improve the quality of service through enhanced care coordination [3]. Vanhaecht et al. [1,2] defined the term 'care pathway' as follows: ' A care pathway is a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period' .
It seems to be consensus on the importance of early intervention in the treatment of mentally ill patients [1,2]. Rutman et al. [4], find that the evidence between the relationship between care pathways and care coordination are sparse.
Care pathways are a way to improve care coordination and operationalise the patient-focused care concept [5]. The aim of care pathways is to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and, ultimately, costs [6]. However, several studies have revealed that care pathways improve the components of care coordination [7][8][9].
Care pathways are not simple or straightforward but rather complex interventions; they comprise separate elements that seem to be essential to the proper functioning of the intervention; they target multiple outcomes and involve multiple interventions, and the 'active component' is difficult to specify [10,11]. Consistent with this definition, the characteristics of care pathways include 'an explicit statement of the goals and key elements based on evidence, best practice, and patients' expectations and their characteristics' . This includes a range of elements: facilitation of communication among team members, patients, and families; coordination of the care process by coordinating the roles and activities of interprofessional care teams, patients, and their relatives; documentation, monitoring, and evaluation of variance and outcomes; and identification of the appropriate resources [10].
Care pathways are popular tools to improve the quality of the diagnostics, treatment, and follow-up of hospital patients [10,12]. Mental healthcare delivery systems and policies have shifted the focus from more extensive psychiatric inpatient settings to community services [3,13,14]. Yet mental health in-patient facilities continue to discharge patients too early, without clear discharge planning, and the post discharge follow-ups do not function properly [15].
People with mental illness often experience stigma and social rejection when returning to their communities [16]. Research reports engagement in 6-12 months community rehabilitation compared to shorter inpatient rehabilitation [17]. Transition of care is particularly important for patients with mental health problems who experience numerous transitions into and out of hospital. This transition comprises hospital discharge, postdischarge support at the next level/location of care and the engagement of the patient and caregiver in these processes [18].
Patients as high-frequency users of psychiatric services in hospital, remaining well for only short periods of time [19]. These patients have diverse preferences for care and face a variety of barriers associated with mental health treatment [19,20].
Many persons with mental health problems will have need of services from different levels at the same time and this context suggest need for easy access to a range of treatment and providers [3,[21][22][23]. Essential elements in this care process are open communication and well-organized, delegated coordinating roles for interprofessional care teams [24,25]. With care pathways, high-performance teams can be built [4]. Chew-Grahee [26] pointed out that, depending on its quality, communication could function as both a promoting factor and a barrier to success. Starfield et al. [27], identified the following key elements in the integrative functions of primary care: first contact, continuous, comprehensive care and coordinated care. These four elements are implicitly incorporated into the health care system to improve outcomes [28]. Vickers et al. [29], noted that expanding integrated mental health care in the primary care setting/services resulted in increased staff and provider satisfaction.
Thus, the aim of a care pathway is to enhance the quality of care across the continuum by improving riskadjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources [11,30,31].
The extent to which these discourses have impacted on individual clinical practice and care experiences remains unclear. Crucially, the involvement of patients at points of transfer of care from the community to inpatient settings and back to the community has been underreported. Tveiten et al. [32], advised giving patients in mental health contexts a voice to express their concerns and have them addressed. A study about patients' knowledge and the power imbalance in the doctor-patient relationship supports our assertions that patients need knowledge and power to participate in shared decisionmaking processes [33].
The study offered several recommendations for enhancing patients' participation by simplifying the trialled pathway and the accompanying guidelines and strategies to improve communication between nurses and general practitioners. Pelto-Piro et al. [34], found that paternalism still clearly appears to be the dominant perspective among staff caring for patients in psychiatric inpatient care settings. Grim et al. [35], described obstacles to legitimizing patient knowledge, including relational issues that patients highlighted: being independent, often being dismissed and unable to edit their testimonies. Health providers typically described workflow issues, patients' insufficient decision-making competence and patients' vulnerability to stress factors.
Care Pathways are developed and implemented across the international health care arena, evidence to support their use has been equivocal, and the understanding of their 'active ingredients' is poor. Care pathways are 'complex interventions' and are increasingly being implemented for a variety of purposes in a range of organizational contexts [1,2,36]. The development and implementation of care pathways are based on interprofessional teamwork, an understanding of the practical organization of care and the integration of a set of evidence-based key interventions [1,2]. A recent study evaluating the implementation of a transitional discharge model, an intervention for community integration of clients with mental health illness, concluded that this implementation provides cost-effective supports to help keep clients in the community and out of hospital [37]. And as reported previously [22] the establishment of relationships among patients, inpatient staff, and community staff is of utmost importance in the transition process between inpatient and community mental health care.
In mental health care pathways involve a significant change work which should give the patients more holistic and coherent services but are hampered by professionals experiencing large workload, frustration and stress associated with registration, and administration systems [38]. A bottom-up implementation strategy for implementing care pathways is recommended [39]. Ruben von Zelm [40] concluded that the implementation and normalization of a care pathway depends on the following: involved professionals, including physicians, to achieve the desired outcomes; understanding and appreciation of the content, goals; and related standardization of the care pathway and play an active role in the improvement team. Implementing the pathway requires: resources, including a care pathway facilitator and a clinical data system; the improvement team's experience, collaboration, and clinical leadership; and individual experience and expertise [12].
The purpose of the study is to provide an overview of studies assessing clinical care pathways for people with mental health problem in the transitional process from hospital to the community.

Methods
Grant and Booth [41] described scoping review as 'a preliminary assessment of potential size and scope of available research literature. ' We followed Arksey and O'Malley's approach [42], and used Levac [43] as a guide, for how to operationalize each step. ' Arksey and O`Malley`s [42] five-stage methodological framework including: 1) identify the research question; 2) identify relevant studies/articles in a literature search; 3) select relevant studies/articles based on inclusion and exclusion criteria; 4) chart the data extraction in a standardized form; and finally, 5) collate, and summarize the results, including the assessment of methodological quality.
A scoping review method was chosen to gain a comprehensive overview of the literature to map key concepts, identify knowledge gaps and convey the breadth and depth of the field [44][45][46]. At the abstract screening stage, we keep the references that meet the inclusion criteria for review and those that we are unsure about. We dismissed the rest. The references we kept was moved to the next stage in the selection process: Arksey and O`Malley [42] full-text screening.

Inclusion and exclusion criteria
The study population included adult individuals (people who are 18 years of age or older). We excluded studies which children were involved. Care pathways for specific mental health diagnoses were not searched for but included if they fitted the overall purpose of the study. We limited the search to 2009 -2020 to allow a scoping search of the published research. We excluded editorials and discussion papers, and research protocols.
Disagreements regarding inclusion or exclusion were resolved through discussion with two other researchers.

Search strategy Stage 1: Identify research questions
First step was to identify the research. The research questions are presented as above. The purpose of the study is to provide an overview of studies assessing clinical care pathways for people with mental health problem in the transitional process from hospital to the community.

Stage 2: Identify relevant studies/articles
To ensure the identification of relevant literature, an experienced librarian critically reviewed the search strategies, search terms and inclusion and exclusion criteria. These searches included studies published in English between 2009 and 2020. The following scientific electronic databases with keywords were systematically searched: ProQuest/Health & Medicine, CINAHL Complete, Cochrane trials and Cochrane reviews, PsychoInfo, Medline, PubMed, and Google Scholar.
The following search terms were included to represent care pathways in mental health in transition from hospital to the community (Medical Subject Headings (MeSH) terms used for searches in Medline are marked with an*): 'care pathways*, 'integrated care pathways*, 'critical pathways' , 'clinical pathways' , 'mental health*, 'adults' , combined with 'transitions from hospital to community' , 'referral' , 'discharge*, 'care planning*, 'coordinating' , 'hospital and mental health services.
We reviewed the reference lists of studies identified-especially systematic reviews and traditional literature reviews-and included relevant studies in the scoping exercise. Key journals were also hand-searched to identify articles that may have fell outside the database and reference list searches. We did hand-search in key-journals, especially in articles in Norwegian Journals, that could not be accessed in full text in English. This were excluded.

Stage 3: Selection of relevant studies based on inclusion and exclusion criteria.
This stage entailed the study selection process as illustrated in a Prisma flow diagram (Fig. 1). The 283 articles in the scoping review resulted in 28 eligible full text articles [44,46].
A total of 250 records were identified by the librarian conducting the systematic literature search and were imported into refence management software. After the removal of 200 abstracts, 28 full-text articles were assessed for eligibility, and then full-text articles excluded with reasons, we had at last 28 studies; studies included in qualitative synthesis 9 and studies included in quantitative synthesis 19, see PRISMA 2009 Flow Diagram, Fig. 1. Two authors (EWS and MFS reviewed the same first, and then FV and VCI reviewed the half (of selected) 200. Disagreement regarding inclusion or exclusion were revolved through discussion. Four authors (EWS, MFS, FV, VCI) read the full text of the remaining 26 records and assessed their eligibility. The four authors conducted meetings to discuss their assessments of the abstracts and full-text articles and the inclusion and exclusion criteria to reach agreement on the studies to be included.
The study population included adults' individuals; people who are 18 years of age or older. We excluded studies which children were involved.
To meet the overall purpose of the scoping review, the included 28 studies focused on care pathways in Fig. 1 Flow-diagram presents a complete overview of the inclusion and exclusion criteria transition between psychiatric hospital and the community mental health services.

Stage 4: Charting the data
We extracted and coded each eligible and included article according to the following descriptive content of the 28 selected studies: 19 quantitative synthesis and nine qualitative syntheses. The descriptive data comprised authors, country of origin, aims, data collection and measurements, study sample and results. The extraction and charting of the data were conducted by author with input from two other researchers. Descriptive content of the selected review studies is presented in Table 1 and Table 2 and Table 3.

Stage 5: Collating, summarizing, and reporting results
To achieve a thematic presentation of the results and avoid bias, the lead author and the two other researchers read and reviewed the included full-text articles. The result of each of the included articles were summarized in separate text description paragraphs by the lead author. The other researchers read the text descriptions and suggested edits when necessary. These summaries were used to identify challenges in care pathways in transitions from hospital to the community for people with mental health problems, including their family and caregivers. The lead author identified what types of approaches and interventions models in the research literature showed evidence and improved the quality and efficiency of care pathways of hospital-to-community transitions for people with mental illness. The research team then discussed the approaches and interventions model of the study results and the challenges, themes and approaches identified. We used the Critical Appraisal Skills program (2018) to assess the methodological quality of the qualitative studies. The tool contains ten questions and assesses quality in three domains: validity, presentation, and impact of study results. We used the Cochrane Collaboration Risk of Bias Tool [47] to evaluate the studies that included quantitative results. This is a six -domain tool with a total of seven items that assess selection (two item), performance (one item), detection (one item), attrition (one item), reporting (one item), and other sources of bias (one item). 'The risk of bias was evaluated independently by all researchers (EWS, MFS, FV, VCI; PC) included the researchers who extracted the data. Discrepancies were resolved by discussions until a consensus was reached [47].

Results
Among 28 selected studies: was 19 quantitative synthesis and nine qualitative syntheses.

Characteristics of the Included Studies
The aims of the six (of 19) review articles with quantitative data were as follows: identify the effectiveness of care pathways in mental health [48] provide evidence to improve the quality and efficiency of special diagnostic groups [49] assess the effects of pathways on practice, patient outcomes, length of stay and hospital costs [50] provide an overview of care and identify components for more effective transitions [51] describe and evaluate interventions in the transition from inpatient to outpatient care [52] and compare mental health pathways in 23 different countries [53].
For nine of 16 articles with both quantitative data and qualitative data, the aims included: examining the duration of untreated psychosis [54] highlighting evidence for each pathway [55] determining the relation between effectiveness and teamwork [56] identifying families' experiences [57] gathering evidence on the quality of information transfer between primary care and specialist health care [14] examining stigma-related influences on pathways [58] understanding patient experiences after discharge from hospitals to community health care services [59] exploring the effects of implementation of health information technologies in care pathways [60] and identifying effective coordination between levels of care and continuity in the transition process [3] and to synthesize the available literature on pathways to care in ' At-Risk mental States/ARMS or prodromal psychosis [61].
Among the primary studies (12 articles), the aims for the three articles with quantitative data were as follows: assess personnel perceptions of care processes and examine whether staff consider the differences between pathways with standardized clinical procedures and pathways without such procedures [62] analyse whether care pathways lead to better organization of care processes [63] determine whether the implementation of a pathway improves diagnosis and treatment in conformity with published guidelines [64].
Of the twelve articles with qualitative data, the aims were as follows: understand the contextual influences, mechanisms and outcomes that affect the implementation of online pathways [13] evaluate how the 'payment by result' model works in community mental health, including its impact on the quality of patient care, staff and primary care [65] assess the extent to which pathways support or inform the creation of elements of frameworks to improve care coordination across the primary hospital care continuum [8] explore the nature of service user involvement in the admission and discharge processes of acute inpatient mental health care [66] gain a better understanding of the transition phase        from psychiatric hospitalization back to community for people diagnosed with schizophrenia [67] identify patients and healthcare professionals challenges and barriers in the transitional process between primary to secondary mental health services [20,22,23] and determine whether implementation of a pathway would improve diagnosis and treatment in conformity with published guidelines [68].
The quality appraisal of the articles that included quantitative research methods indicated that the studies had a high risk of bias. One of three studies met all ten criteria suggested by Critical Appraisal Skills Programme (CASP). Other bias description' was noted in 16 of 28 of the articles had implementation problems, with small sample size [47,69].

Care Pathways Challenges between Mental Health Services
There were six major themes identified in the articles related to the challenges and barriers of pathways in the transition from hospital to community: (a) Organization, (b) Resources, (c) Information and Documentation, (d) Patients and Families, (e) Clinical Care and Teamwork, and (f ) Ethics.

Organization
Research found that the first contact for patients with psychosis was a physician, but the referral source was emergency services [54]. Viggiano et al. [51], found that a core set of transition intervention components could stimulate the development of interventions at the patient, provider, and system levels. More effective transitions in mental health care pathways included special procedural guidelines and instructions and links to national guidelines provided in the transition phase; prehospital, hospital, outpatient, home [55]. Amaral et al. [55], indicated the importance of the first contact in pathways to mental health care, and that there is a lack of integration between emergency departments, hospitals, and community services. Hasson-Ohayon et al. [67], revealed different characteristics of the transition phase for people with schizophrenia who had just returned to the community following a psychiatric hospitalization. The article emphasized the non-linear nature of the transition process and the special challenges involved. Storm et al. [3], found continuity challenges in care during transitions and services for people with serious mental illness. Effective approaches addressed coordination challenges and resulted in improvements in service utilization, social functioning, and quality of life. Seys et al. [63], identified a significant difference between care processes with and without care pathways, for 'coordination of care' and 'follow-up care' in primary care. Biringer et al. [62], found that Norwegian employees considered follow-up care processes and collaboration with primary care to be poorer than the other dimensions of care organizations. Care processes with written clinical procedures were reported to be better organized than processes without such standardization. Sather et al. [22], exploring community health personnel's experiences of care pathways in patient transition between inpatient and community mental health services, suggested that systems and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathway of care.

Resources and outcomes
Allen et al. [48], found that there was a positive impact on length of stay and hospital costs with care pathways. Khandaker et al. [65], indicated that care pathways were effective and allowed for active case management and clear clinical leadership. The care pathway led to more focused interventions being offered. Vigod et al. [52], concluded that transitional intervention components are feasible and likely to be cost-effective. Facilitated predischarge, post-discharge, and transition processes; and promoted timely communication of inpatient staff with outpatient care or community service providers after discharge was successful components that reduced hospital readmission. Chen et al. , [49] found that care pathways showed promising results in increasing the quality and efficiency of care for patients diagnosed with schizophrenia but that more evidence was needed. Akehurst et al. [13], concluded that the use of localized, online evidencebased care pathways across primary to secondary care increased over time and showed that care pathways were used in leadership, relationships, and networks to support decision making and referrals and provided information on the availability of resources. Neame et al. [60], found that health information technology supported care pathways and improved objectively measured patient outcomes.

Information and documentation
Allen et al. , [48] found that care pathways are effective with patients with predictable mental health symptoms. Care pathways improve documentation, communication, and change professionals' behaviour positively. Rotter et al. , [50] found that care pathways reduced in-hospital complications and improved documentation without negatively impact to the length of stay and hospital costs. Durbin et al. , [14] focused on the content and/or timing of written communications and found variation in the quality of communication between care pathways and mental health specialists and that patient-centred care was among the least investigated topics. Research found that existing and new care pathways in four communities had positive effects on exchanging information; formulating and sharing goals; defining and knowing each other's roles, expectations, and competences; and promoted the relationship between care pathways and care coordination [13]. Sather et al. [20], found that that clinical pathways are useful for securing key objectives at the interface between hospital and community based psychiatric care. Improved information sharing in/between all care systems is imperative to strengthen patients' participation in decision-making, ownership of care planning and improving adherence to treatment. Adequate communication and proper documentation systems were factors in this success by avoiding communication errors that were the main barriers. Biringer et al. [58], found that care processes with a written clinical procedure were better organized than processes without such standardization. Gronholm et al. [58], identified themes related to the relationship between stigma and care pathways among people experiencing first-episode psychosis or at a clinically defined risk of developing psychotic disorder. The findings indicated that a lack of information could result in increased perceived stigma. Akehurst et al. [13], showed that care pathways were used to support decision making and referrals and provided information on the availability of resources. Sather et al. [23], emphasized that former patients reported shared decision making more precisely as informed shared decision making, and that shared information between all parties is key. Teshager et al. [68], found that stigma and lack of awareness about where treatment is available were barriers to seeking appropriate care.

Patient and family's participation
Steinacher et al. [63], tested the effects of clinical care pathways for schizophrenia in open general psychiatric wards with two different implementation strategies. The authors offered no explanation for their findings. Due to the lack of resources the role of the service user was diminished [66]. Patients revealed oscillation between feelings of strength and vitality to vulnerability and despair in the transition phase and emphasized the importance of supportive relationships and work [67]. Doody et al. [57], explore families' experiences of engaging in care planning within adult mental health services. Families perceived that care planning was uncoordinated and that their lived experiences were not always appreciated; they did not regularly experience collaborative decision making but did experience communication constraints, protection of confidentiality and providers' claims of 'insider knowledge' of service users. Sather et al. [20,22,23], suggested that improved information sharing in/between all care systems is imperative to strengthen patients' participation in decision making, ownership of the care plan and improve adherence to treatment. Patient participation in sketching of care plans were a success factor. Storm et al. [3], emphasized that effective coordination of pathways of care resulted in better social functioning and quality of life. Shared decision-making support for caregivers was found to be important, especially when patients needed complicated medication regimes. Teshager et al. [68], found that there is significant delay in seeking modern psychiatric treatment with religious healers providing the first source of help for mental illness. Allan et al. [61], found that mental health professionals, and general practitioners played a key role in help seeking. Family involvement was also found to be an important factor.

Clinical care and teamwork
Allen et al. [48], found that care pathways promoted interprofessional aspects of care and positively influenced professional attitudes. Durbin et al. [14], found that patient-centered care was among the least investigated topics between care pathways and mental health specialists. Deneckre et al. , [56] revealed that care pathways have the potential to support interprofessional teams in enhancing teamwork. Khandaker et al. [65], found that a care pathway model for community mental health services led to more focused interventions being offered and implemented, resulting in positive changes; staff were also held accountable for clear standards of care. Arbitrary time frames, strict criteria and thresholds for different teams could create issues. Improved communication, a flexible and patient-centred approach, staff supervision, and increased support in primary care were felt to be central to this model working efficiently and effectively. Hasson-Ohayon et al. [67], reported the formal professional support as important to their recovery process in general and in their transition to the community, mostly associated with the need for continued care and having a therapeutic setting to attend. Sather et al. [20,22], suggested that patients' participation in plans and working hours of ambulant teams were success factors. A key person to handle all information and communication between levels of care was recommended.

Ethical issues
Volpe et al. [53], found that the role of general practitioners could either decrease or increase the referral time to care pathways. Stigma and discrimination towards patients with mental illness are limiting factors for the equal delivery of mental healthcare. Wright et al. [66], focused on knowledge sharing at points of transition of care into and out of inpatient mental health services. The findings showed a loss of the voice of service users at key transition points. It was concluded that these encounters can have lasting negative effects, indicating the importance of ensuring that service users have a voice in determining what happens to them. Gronholm et al. [58], identified themes in relation to stigma on pathways to care among a target population and illustrates the complex way stigma-related processes can influence help-seeking and service contact among first-episode psychosis and at-risk groups. Lack of information could result in increased perceived stigma. Sather et al. [20,22], exploring community health personnel experiences of care pathways in patient transition between inpatient and community mental health services, suggested respectful communication to avoid humiliating the patients. The complexity of welfare systems negatively affected patient dignity. Mutcheler et al. [59], identified themes related to transition, patient safety, supported autonomy, and activities in the community. Barriers were poverty, interpersonal difficulties, and stigma. Teshager et al. [68], also found that stigma and lack of awareness about where treatment is available were barriers to seeking appropriate care for patients with various diagnosis of mental illness.

Discussion
The literature review identified themes and issues relating to: Organization; Resources and Outcomes; Information and Documentation; Patient and Family's Participation; Clinical Care and Teamwork; and Ethics. Articles supporting the included studies are indicated with reference number in italics. Issue concerting the first of our themes, organization, seem to embrace our findings concerning improving pathways of care, and system and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care. Effective transitional interventions at patient, provider and system levels were found to be feasible and likely to be cost-effective. To address transitions in the health mental population more effectively care pathways need special procedural guidelines, instructions and links to national guidelines provided in the prehospital, hospital, outpatient, and home phase [51]. A study of Sather [70] concluded that to achieve sustainable integrated care, pathways of care should also describe content of the transitional phase in and out of hospitals and community services.
Facilitated pre-discharge, post-discharge, and transition processes, and promoted timely communication of inpatient staff with outpatient care or community service providers after discharge were successful components [52]. First contact is important in pathways of mental health care, and there is lack of integration between emergency departments, hospitals, and community [55]. Care pathways led to better coordination of care and follow up with primary care [62]. The first contact for patients was a physician, but the referral source was emergency services. Ethnic determinants of the pathway, or the impact of the pathway to care on treatment delay was not found [54]. Earlier research has stated that the context of care pathways implemented in complex organizations must be considered in both external and internal contexts and have better descriptions of implementations and the contextual factors [12,71]. An understanding of the development changes and implementation process of a particular context is critical to support multidisciplinary teams in their search for excellence; and it is recommended that clinicians and managers should evaluate each of their individual projects to ensure that patient and organizational outcomes are improved [72,73]. Information technology supported care pathways and improved objectively measured patient outcomes and resources [13,60]. It supports decision-making and referral, and available resources; made more cost-effective care pathways and allows for active case management and clear leadership, relationships, support decision-making and referral, and available resources [13,59,63]. It was found that care pathways may lead to better clinical outcomes, ensure more focused interventions and be valued by workforce [48,52,65]. This is in line with Mater et al. [74], who emphasized that development and implementation of care pathways are knowledge-based systems, care pathways optimize medical behaviour, and as clinical decision support systems, care pathways play a role in improving healthcare quality [74]. Our review revealed that pathways are a solution to safety problems and can improve extended care episodes as part of preventing unnecessary hospitalization [3,59,66]. Development and implementation of care pathways is labour-intensive; thus, resources should be optimally used.
Care pathways in mental health were found to be effective and improve information and documentation, providing patients with enough detail about their care and structured, documented plans at the appropriate time. Former mental health patients reported that shared information between all parties involved in care pathways is key. Proper documentation systems between health personnel, and patient participation in plans were success factors.
Opportunities for information sharing, implementation of systematic plans, use of e-messages were identified for successful patient transition, and the absence and systematic plans and delay in information sharing were barriers found to impede the patients' transition between levels of care [20,22,23]. Care pathways were found to reduce in-hospital complications and improved documentation without negative impact on the length of stay and hospital cost [50]. This is in line with research in somatic health care [75,76] that has shown that the implementation of a care pathway leads to increased or clearer documentation of care, and better interprofessional teamwork and better organized care [77,78].
Continuous collaborative decision-making and patient and family's participation was found to be an important factor related to pathways to care. Care pathways affected patient safety, supported autonomy and activities in community [59]. It was found that patients revealed oscillation between feelings of strength and vitality to vulnerability and despair in transition phase and emphasized supportive relationships and work [67]. Continuous collaborative decision making was emphasized, but this was not regularly experienced. Families perceived that care planning was uncoordinated and that their lived experiences were not always appreciated [57]. It was also found that improved information sharing in/between all care systems is imperative to strengthen patients' participation in decision making, ownership of care plans and improve adherence to treatment. Additional, patient participation in care plans were success factor [20,22,23] as well as shared decision-making support for caregivers. Power and trust seem to be important factors that may increase as well as decrease patients' dependency, particularly as information overload may increase uncertainty [79].
Clinical care and teamwork were found to be important in pathways of care; collaboration between mental health and other professionals was a guarantee that planned activities meet patients' needs, and pathways gave more interprofessional aspects, changing professional attitude positively [48]. Regular meetings sharing key information and avoidance of delays that extend inpatient status and block satisfactory transition to the community setting are key [22]. It was revealed that care pathways have the potential to support interprofessional teams in enhancing teamwork. The most frequent positive effects were on staff knowledge, interprofessional documentation, team communication and team relations 56 . Open communication, well organized and delegated coordinating roles for interprofessional care team delivery are essential elements so that the service is consistent with agreements reached with patients and relatives [24,25].
Mental health professionals support is key in help seeking for patients and important to their recovery process in general alongside transition to the community [67]. Patient-centred care was among the least investigated topics between mental health specialists [14]. Research indicated that creating reliable treatment and care processes, a stimulating social climate in wards, and better staff-patient communication enhances patient perceptions of safety during inpatient care [79]. The review showed considerable variations in the ethics relating to mental health care pathways. The role of general practitioners could either decrease or increase the referral time, and stigma and discrimination towards patients with mental illness are limiting factors for the equal delivery of mental healthcare [53]. The results highlighted the disconnect that occurs for patients as they transition from hospitals back to their communities, indicating the need for effective, ethical transitional interventions that target these challenges [59]. Lack of information could result in increased perceived stigma and devaluation of people with mental health challenges. Stigma and lack of awareness where treatment is available were barriers to seeking appropriate care for patients with various diagnoses of mental illness. The complexity of welfare systems negatively affected patient dignity, with patients and health personnel viewing treatment options differently. Respectful communication to avoid humiliating the patients was emphasized [20,66]. Without ownership in decision making, patients in psychiatric inpatient care settings may prove less treatment compliant [34]. A recent study suggested that greater epistemic justice might be achieved by shared decision-making processes in which patients are engaged as a full, collaborative partner in their care [35]. Many of the studies were characterized by small study samples, no randomization and lack of control group, which increases the risk of bias and the ability to draw conclusions about outcomes [47]. Despite a comprehensive literature search of multiple databases that used broad search terms, the search may have missed relevant studies. These searches did not result in the inclusion of additional studies. It is recommended to consult experts in the fields as a separate but optional stage in the search strategy [42,45]. However, expert consultation was not feasible in this study. Discussions among the authors on the depth and breadth of the review during the study selection stage may have resulted in a reduction of the scope. An assessment of methodological quality of the studies is debated within the scoping review tradition (Pham et al.; [80]). In the present review, the quality assessment was performed to identify the strength of the evidence base and was not used as a tool for the exclusion of studies.

Conclusion
In pathways of care, systems and procedures can ensure clear responsibilities and transparency. Information technology could support decision-making and referral to improve objectively patient outcomes in care pathways. Collaboration between mental health and other professionals can guarantee that planned activities meet patients' needs through regular meetings sharing key information. Around-the-clock ambulant teams in the community are important alongside informed shared decision making, information and documentation between all parties to support patient participation. Respectful communication can avoid patient humiliation that could undermine treatment compliance. The combination of professional and patient perspectives best promotes positive outcomes from sustainable care pathways.